Friday, June 19, 2009

ADHD and Medication: cause for alarm?

Just when the calls about Swine (H1N1)Flu started to abate, the phone and email box filled up this week with concerns about children taking medication for Atttention Deficit Hyperactivity Disorder.

That’s because it was big news across all media this week. A study, "Sudden Death and Use of Stimulation Medications in Youths"* has parents and providers everywhere scrutinizing the results. It is generally agreed that somewhere near 5% of the general pediatric population has a diagnosis of ADHD, so that means this information has the potential to affect at least one kid in every classroom. In addition to legitimate use of medication one needs to consider the current fad of students buying or borrowing the prescribed medications of their friends to use as study aids. The results of this current research ask us to sit up and pay attention.

What is the brouhaha about? This epidemiological study from Columbia University and the New York State Psychiatric Institute published in the June issue of the American Journal of Psychiatry examined the risk of sudden unexplained death(SUD) in young people taking stimulant medication (eg Methylphenidate (Ritalin).

The study used official vital statistics from across the US and identified 564 cases of SUD in children ages 7 through 19. They were compared with 564 youth who died as passengers in motor vehicle accidents. Data was collected and studied for the years 1985 to 1996. Without going into exhaustive detail, suffice it to say that there is very little criticism about the methodology in this ambitious work. The control group was well matched, the methods of inquiry and verification were excellent, several confounding factors (like underlying diseases in victims) were accounted for, and the results appear to be reliable and statistically significant.Results showed that ten children (1.8%) of the SUD group showed evidence of stimulant use (almost all methylphenidate, the generic name for Ritalin) as opposed to only two (0.4%) of the motor vehicle fatality group.

Here are some of the most fundamental concerns and questions raised by this new information:

The data in this study was collected from records more than twenty years ago and the newer formulations of longer acting medications (eg Adderal XR, Concerta) were not prescribed yet.

A statistical association does not prove causality. For instance, it is possible that the genes that code for ADHD in an individual also put that person at a slightly higher risk of a sudden cardiac event.

The numbers of exposed children was extremely small. Although the data showed a statistically significant difference, we need to remember that the percentages still remain extremely low.

In a misguided haste to dismiss medications for ADHD as unsafe, we must not forget the very high likelihood of harmful and unhealthy behaviors associated with untreated ADHD. Alcoholism, motor vehicle accidents, school failure, antisocial activity and other accidents are many times higher in adolescents who are not on medication when it is indicated.

This study makes people want to do something (like an EKG) before prescribing medication even though the study does not at all address whether there is any way to predict who might be at risk from the medications.

A statistical nugget to underscore the rarity of the problem was pointed out by Dr Laurence Greenhill, a child psychiatrist in practice in Mamaroneck, one of the lead authors in the study, and the President-elect of the American Academy of Child and Adolescent Psychiatry. It would be necessary to treat 250,000 children before one might expect to encounter SUD associated with stimulant treatment. On the other hand, it would only take treating two children with medication for their ADHD to see beneficial effects on the symptoms.

What is the current advice for kids already on medication?Most clinicians have been alerted to the statistical increase in SUD over the past few years. The current recommendation by the FDA, the American Academy of Pediatrics, and the American Heart Association is to have a careful assessment of family cardiac history done before prescribing medication. Only when such a positive history exists is an electrocardiogram or other test recommended. For others, no screening cardiac tests are necessary. If there is any question of a family history, it should be discussed with the prescribing doctor.

Although it is fair to downplay the risks in diagnosed patients who need the medications in order to function well, it is also fair to point out to those who might abuse stimulants that every medication has risks, known and unknown. When an otherwise healthy college sophomore combines Adderal with Red Bull, coffee, alcohol, insufficient sleep and stress, any number of side effects are possible, including cardiac ones.